Innovation in Community based Practice

1. Diabetic Retina Screen
Screening for Diabetic Retinopathy in Ireland
Mark Cahill MCh, FRCSI (Ophth)
Clinical Lead
Global Vision

2. The Eye
Retina - layer like wet tissue paper that lines the inside of the eye
Macula - Important central area of retina

3. What is Diabetic Retinopathy
5.6% of the Irish population have Diabetes – approximately 210,000 people
Diabetic Retinopathy is the term used for two different types of changes in the
retina which can affect your sight.
1.
Proliferative Diabetic Retinopathy:
Fragile new blood vessels form in a gradual way on the surface of the
retina.
2.
Diabetic Macular Oedema:
Leaky blood vessels affect the macula, the important central part of
the retina.

4. Proliferative Diabetic Retinopathy

5. Diabetic Macular Oedema

6. Anyone with Diabetes can develop Diabetic Retinopathy
Main risk factors:
Duration of disease
High blood sugars
High blood pressure
High blood cholesterol
Pregnancy (not gestational diabetes). Pregnancy in women with
diabetes can worsen Diabetic Retinopathy

7. What are the symptoms of Diabetic Retinopathy?
There may be no symptoms or pain in the early stages of Diabetic Retinopathy
Symptoms include:
Blurred vision or any changes in your sight
Black spots or “floaters” that appear to float in your eye
Trouble with seeing things at the side of your sight
Early detection and treatment can help to avoid sight loss

8. How is Diabetic Retinopathy Detected?
Diabetic Retinopathy can be detected in two ways:
1. During a full eye exam
2. Digital Photographic Screening
Two photographs of each eye with specific dimensions
Stored using special software (Digital Healthcare)
3 step analysis by graders; supervised by Eye Doctor
Quality Assured (internal and external)
Regular eye tests for glasses do not replace Diabetic Retinopathy screening. It
is important to have both

9. Compelling case for Diabetic Retinopathy screening
Diabetic Retinopathy
Role of screening
• # 1 Cause of blindness in people
• Annual screening examinations
aged 18 – 65
• Incidence of 50 – 65 per 100,000
people with diabetes
•Based just on registered patients
the State spends €4.8 m per year
supporting people with diabetes
related blindness (and an extra
€600k on new cases each year)*
can prevent blindness in 96% of
cases
• Screening is extremely cost
effective using the quality –
adjusted life year (QALY) model
• Fulfils the Wilson and Jungner
criteria for a screening programme
• Digital eye photographs and
grading is the Gold standard
*Does not include all the indirect socio-economic costs associated with blindness

10. Diabetic Retina ScreenThe National Diabetic Retinal Screening Programme
National Cancer Screening Service
Dr Margaret Morgan - Clinical Lead
Pat Cafferty - Programme Manager
Leahna Kelly – Programme Co-ordinator
Contract out Photography and Grading service to two Providers
Global Vision
Leinster except Meath and Westmeath
Medical Imaging
Rest of the country
(Competitive tender awarded in December 2012)

11. Client Journey
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Eligible Clients - 12+ with Diabetes Mellitus
Source of clients – Diabetes Register
Client consents with NCSS to join the programme
Client scheduled, screened (photographed) & graded
Results to GP
Results to client
Onward referral to treatment(if applicable)
Contacted by treatment centre
Stays within hospital or returned for annual screening

12. Our Service
• Scheduling & result communication services
• Digital screening with dilation
• 2 photos of each eye – one disc centred, one macula
centred
• Grading services
• Slit Lamp examination for ungradeable clients

13. Global Vision
Screening (photography) locations:
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Thomas Court Primary Care Centre, Dublin
Diabetes Ireland - Santry
VHI Swiftcare - Dundrum
Cedar Clinic, Portlaoise
Vista Clinic, Naas
Ayrfield Medical Centre, Kilkenny
Slaney Medical, Enniscorthy

14. Digital Photographic Screening - Colour Photos

15. Grading
• Images go through 3 stages
of grading depending on
findings
• Primary Grade – all Clients
• Secondary Grade – all
disease positive clients and
10% of normal
• Arbitration Grade – only if
difference between Primary
& Secondary Grade
• Referral Outcome Grading –
All Clients being referred to
treatment (Ophthalmologist)

16. Results
Patient:
– Normal: letter & annual recall
– DR: referral to treatment letter
– NDED: referral to treatment letter
– Ungradeable: referral to treatment
letter
Grading Report:
R (retinopathy) code
M (macular oedema) code
Certain non diabetic eye diseases
(NDED)
GP: grading report
Treatment Centre: grading report with
timeline required for referral
(urgent 2-4 weeks, routine 13-18 weeks)

17. Hospital Treatment referral centres
• The Mater Misericordiae Hospital
• The Royal Victoria Eye and Ear Hospital
• Waterford Regional Hospital
• Dedicated clinics (3-6 clinics per week)

18. Global Vision
First patient screened 11th March 2013
Global Vision Team
Graders & Photographers = 8
Ophthalmologists = 4
Clinical Lead Mark Cahill
Programme Ophthalmologist Pat McGettrick
Administration team & Service Leads = 3
Programme Director Sinead O Connor
Programme Manager Adele Dunne
IT Support = 1

19. Global Vision
Target population is 145,000
30% of target screening population will be invited this year
(3,200 to date, 300 per week)
70% of target screening population will be invited next year
Photography and Grading accreditation with Peter Scanlon and
Steve Aldington in Gloucestershire NHS Trust

20. DRS patient information

21. Acknowledgements
National Cancer Screening Service
Heart of England Diabetic Retinopathy Screening Centre,
Birmingham
Global Vision Photographers and Graders